Hi all!
My institution does weight-based heparin infusions with aPTT guided dose adjustments done by nursing according to detailed titration instructions.
We often see medication errors in which the nurse enters the dose into the incorrect field. All doses should be entered in "unit/kg/hr," but the RN often mistakenly enters the dose in the "mL/hr" field in Alaris -- of course this ends up in the patient receiving the wrong dose.
In the Alaris pump, the "rate mL/hr" field shows first, and the RN must toggle down to the "dose unit/kg/hr" field (see image attached). I believe this is the greatest source of the error, but Alaris representatives indicated that switching these fields would effect all institutions that use Alaris pumps.
I have tried to attack this from several angles and I am looking for some any other creative ideas to help prevent this mistake!